Information Collection

Request for Earnings Information

IC 13778 under ICR 200811-1215-007 · OMB 1215-0112.

Documents and Forms

Document Name Document Type
Form LS-426 Request for Earnings Information Form
LS-426 Request for Earnings Information ls-426 new.pdf www.dol.gov/esa/owcp/dlhwc/ls-426.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Request for Earnings Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	LS-426	Request for Earnings Information	ls-426 new.pdf	http://www.dol.gov/esa/owcp/dlhwc/ls-426.pdf	Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL Privacy Act Notice DOL/ ESA-15	FR Citation: 58 FR 49599

Number of Respondents: 1,600	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,600	0	1,600
Annual IC Time Burden (Hours)	400	0	400
Annual IC Cost Burden (Dollars)	720	-280	1,000

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.